Trombolys vid akut ischemisk stroke. Kritisk analys av aktuell kunskapsfront

Thrombolysis is a highly promising treatment in acute ischaemic stroke. There is evidence of positive effects at least up to three hours and most probably up to six. The risk of intracranial haemorrhage is increased fourfold with thrombolysis; risk factors other than the treatment as such have not been identified for certain; the risk is not related to giving thrombolysis during the 0-3 as opposed to the 3-6 hour time window. There is a non-significant excess of deaths, ranging from a small reduction to a substantial excess. There is not enough evidence to answer several questions regarding the influence of patient- and stroke characteristics on effectsize; death; and risk of intracranial haemorrhage. Giving priority to new large randomized controlled trials is essential to achieve this knowledge

Reduced risk of death with warfarin - results of an observational nationwide study of 20 442 patients with atrial fibrillation and ischaemic stroke

BackgroundWarfarin is demonstrated to be superior in efficacy over antiplatelet agents for the prevention of stroke, but the relationship between warfarin and mortality is less clear. Our aim was to investigate this relationship in a large cohort of unselected patients with atrial fibrillation and ischaemic stroke. MethodsThis observational study was based on patients who were discharged alive and registered in the Swedish Stroke Register in 2001 through 2005. Vital status was retrieved by linkage to the Swedish Cause of Death Register. We calculated a propensity score for the likelihood of warfarin prescription at discharge from hospital. The risk of death and 95% confidence intervals were estimated in Cox regression models. ResultsOut of the 20442 patients with atrial fibrillation and ischaemic stroke (mean age=795 years), 31% (n=6399) were prescribed warfarin. After adjustment for the propensity score, warfarin was associated with a reduced risk of death (067; 95% confidence interval, 063-071). The crude rate (per 100 person-years) of fatal non-haemorrhagic stroke was lower in patients who received warfarin (160; 95% confidence interval, 134-189) compared to those who received antiplatelet (683; 95% confidence interval, 642-725). The rates (per 100 person-years) of fatal haemorrhagic stroke were 021 (95% confidence interval, 012-032) and 043 (95% confidence interval, 034-055) in patients prescribed warfarin and antiplatelet therapy, respectively. ConclusionsIn addition to its established benefit for stroke prevention, warfarin therapy in patients with atrial fibrillation and ischaemic stroke was associated with a reduced risk of death, without an increased risk of fatal haemorrhagic stroke

The prevalence of atrial fibrillation in a geographically well-defined population in Northern Sweden: implications for anticoagulation prophylaxis.

Objectives: The aims of this study were to evaluate the community-based prevalence of atrial fibrillation (AF) in a western society using a geographically well-defined population in the northern part of Sweden as a reference and to estimate the proportion of patients eligible for oral anticoagulation (OAC) prophylactic therapy according to the stroke risk indices CHADS(2) and CHA(2) DS(2) -VASc. Bleeding risk was assessed using the HAS-BLED score. Design: The study population was recruited from AURICULA, a Swedish national quality register for patients receiving anticoagulation treatment. All patients with the diagnosis AF in the catchment area are registered in AURICULA. Results: Of the 65,532 inhabitants in the catchment area, 1616 were diagnosed with AF (1200 cases were characterized as chronic AF). Thus, the overall prevalence of AF was 2.5%. The prevalence increased with age from 6.3% in patients over 55 years of age to 13.8% in those over 80 years. The prevalence was higher in men than in women in all age groups. Overall, 56.3% and 85.1% of the population were at high risk of stroke (≥2 points) according to CHADS(2) and CHA(2) DS(2) -VASc, respectively. In addition, 26.9% had an increased bleeding risk according to HAS-BLED. Conclusion: Within this large Caucasian population, we identified the highest community-based prevalence of AF to date. The prevalence was strongly associated with increasing age and male gender. Using CHA(2) DS(2) -VASc instead of CHADS(2) widened the indication for OAC prophylactic therapy of AF in this population

Functional outcome 3 months after stroke predicts long-term survival

Background: When reporting stroke survival and prognostic factors with a possible effect on outcome, the starting point for the observation of a clinical cohort usually is the onset of stroke or the acute admission of a patient. Thus, acute and early mortality inflict prognosis on long-term outcome. In order to give a more robust analysis of long-term survival after the acute period we chose to start our observation with 3-month survivors. Methods: We used data from Riks-Stroke, the Swedish quality register for stroke care, together with survival information from the Swedish population register to explore the influence of disability level 3 months after stroke on long-term survival. The main analysis included 15,959 stroke patients, registered during 2001-2002, who had been independent in primary activities of daily living before stroke, had suffered an ischaemic or a haemorrhagic stroke and reported no previous stroke. Results: Impaired functional outcome after stroke was an independent predictor of poor survival. Patients with modified Rankin scale (mRS) grades 3, 4 and 5 had hazard ratios of 1.7, 2.5 and 3.8, respectively, as compared with patients with lower mRS grades. In addition to high mRS, male sex, high age, diabetes, smoking, hypertension therapy at stroke onset, atrial fibrillation and depressed mood were also recognized as significant predictors of poor survival using a multiple Cox regression model. Conclusion: The influence of disability on survival is stronger than that of several other well-known prognostic factors. This finding indicates that any intervention in the acute phase that may improve functional status at 3 months will also have favourable secondary effects on survival in the long term

Hemorrhage after ischemic stroke - relation to age and previous hemorrhage in a nationwide cohort of 58 868 patients

Background In randomized controlled trials of secondary prevention after stroke, the risk of hemorrhage varies between 1% and 5% per year in patients with antithrombotic therapy, i.e. anticoagulants and antiplatelets. Aim To explore the rate and the risk of hemorrhage after stroke in a nationwide cohort. Methods We identified 58 868 first ever ischemic stroke patients in the Swedish Stroke Register during 2001 to 2005 (=index stroke) and followed them by record linkage to the National Patient Register. Rates of hemorrhage and hazard ratios, for comparisons of rates between subgroups, were calculated. Results Of the 58 586 ischemic stroke patients identified, 5527 (9.4%) had a history of hemorrhage. During follow-up (mean 2.0 years), 2876 patients endured a hemorrhage, giving an average hemorrhage rate of 2.6 (95% confidence interval 2.5-2.7) per 100 person-years. After index stroke, 11% of the patients were discharged with anticoagulants, and 79% with antiplatelets. Given the differences in baseline characteristics, the hemorrhage rates (per 100 person-years) were 2.5 (95% confidence interval 2.2-2.8), 2.4 (95% confidence interval 2.32.5), and 3.8 (95% confidence interval 3.5-4.2) in patients prescribed anticoagulants, antiplatelets, and no antithrombotics, respectively. There was an increased risk of hemorrhage in patients <75 years compared with those <75 years (hazard ratio?=?1.61, 95% confidence interval 1.49-1.73) and in patients with previous hemorrhages compared with those without (hazard ratio = 1.82, 95% confidence interval 1.64-2.02). Conclusions When antithrombotics were used in large-scale clinical practice, the observed rates of hemorrhage were similar with anticoagulant therapy but increased with antiplatelet therapy compared with rates reported in randomized controlled trials. Old age and previous hemorrhage were associated with an increased risk of hemorrhage after an ischemic stroke

Age relations of cardiovascular risk factors in a traditional Melanesian society: the Kitava Study

This study examined cross-sectional age relations of blood pressure, anthropometric indexes, serum lipids, and hemostatic variables in 203 subsistence horticulturists aged 20-86 y in Kitava, Trobriand Islands, Papua New Guinea. The population is characterized by extreme leanness (despite food abundance), low blood pressure, low plasma plasminogen activator inhibitor 1 activity, and rarity of cardiovascular disease. Tubers, fruit, fish, and coconut are dietary staples whereas dairy products, refined fat and sugar, cereals, and alcohol are absent and salt intake is low. Although diastolic blood pressure was not associated with age in Kitavans, systolic blood pressure increased linearly after 50 y of age in both sexes. Body mass index decreased with age in both sexes. Serum total cholesterol, triacylglycerol, low-density-lipoprotein cholesterol, and apolipoprotein B increased in males between 20 and 50 y of age, whereas high-density-lipoprotein cholesterol and apolipoprotein A-I decreased. There were no significant differences in these indexes with age in the few females studied. A slight linear age-related increase of lipoprotein(a) was present in males. Plasma fibrinogen, factor VII clotting activity, factor VIII clotting activity, and von Willebrand factor antigen increased with age in both sexes but plasminogen activator inhibitor 1 activity did not. The modest or absent relations between the indexes measured and age are apparently important explanations of the virtual nonexistence of stroke and ischemic heart disease in Kitava

Antikoagulantia efter akut ischemisk stroke med förmaksflimmer - Frågan om rätt tidpunkt för insättning kräver randomiserad klinisk prövning.

Early or delayed onset of oral anticoagulant therapy in patients with acute ischemic stroke with atrial fibrillation is an unsolved issue. Retrospectively, 294 patient records at two hospitals were scrutinized according to a protocol consisting of 20 items regarding choice of therapy (warfarin or NOAC), time for onset of therapy, CT findings of bleeding, capacity to swallow, and occurrence of clinical deterioration during the acute phase. Out of 249 patients who survived the acute phase, 116 (47%) patients were given a new prescription of warfarin or NOAC at discharge, while 43 (17 %) continued with anticoagulant therapy already prescribed before the onset of stroke. The median value for new prescriptions in relation to stroke admission was 5 days. The pattern was similar for warfarin and NOAC. Patients in whom anticoagulant therapy was started early were characterized by good capacity to swallow and no signs of bleeding on initial CT. The question »early or delayed onset of oral anticoagulant therapy after acute ischemic stroke with atrial fibrillation« needs to be tested in a randomized clinical trial